Hospitals are being challenged to improve clinical documentation within their organizations. Accurate and complete records demonstrate the complexity of the patient’s condition, justify the intensity of care and services delivered, improve outcomes and ensure equitable reimbursement. Inadequate documentation creates a ripple effect throughout the entire organization, and can cause compliance issues, greater liability and sub-optimized reimbursement. ChartWise:CDI is a comprehensive computer-assisted clinical documentation improvement (CACDI) software application that provides a proactive method for improving documentation in an efficient, systematic and sustainable manner, via a clinically intelligent easy-to-use tool.
When first developing their CDI program, Colquitt Regional Medical Center in Moultrie, Georgia enlisted the help of a consultant/management firm that provided software for tracking queries. However, the solution proved cumbersome, time consuming and inefficient, and much of the information provided by the firm was readily available at no cost through public sources. It soon became clear that the cost of the management contract far outweighed the benefit to the program. Colquitt felt that they needed a better solution for managing the CDI process, including creation and tracking of electronic queries, and reporting that gave them meaningful metrics.
Search and Action:
After seeing the limitations of the previous software tool, Carla Fowler, RN, MBA, Director of Case Management and Clinical Documentation Improvement at the medical center, wanted a robust software program that would help her manage the CDI process. The software had to be interactive, user-friendly and efficient. “Our previous CDI software was a manual labor nightmare that simply didn’t provide enough value to justify the cost. The tremendous amount of time it took to update the databases just to attempt to report a return on investment ultimately impacted the cost of running the CDI program,” stated Fowler. “We knew there was a very strong need for our CDI program but we continued to struggle with an effective process to manage our queries, document our impact and justify the costs of implementing and maintaining the program. It wasn’t until we found ChartWise that we realized just how integral a system like this could become to the success of our CDI department.”
Fowler and Colquitt Regional Medical Center began a search for the right CDI vendor and found that many firms would advertise their software, but then highlight the value of their consulting services, belying the fact that their software was limited. “We realized that a strong software program was our chief priority and we weren’t interested in the management or consultant products,” said Fowler. “Once we committed to that approach the process became much simpler. We were able to focus more singularly on finding software that would help us manage the CDI process effectively and not be just a data repository.”
Top Notch Solution and Service:
When the decision was made to go with ChartWise, things moved quickly for Colquitt Regional. Because the software is web-based, they had access to the software almost immediately. Implementation of the HL7 messaging to import census data was completed in less than a month and training was conducted onsite in both classroom and individualized settings. “The ChartWise training was interactive, informative and extremely flexible,” stated Fowler. “They designed the program to meet our specific needs. Their technical support has been incredible and their response time is very fast.”
Since implementation, Colquitt Regional Medical Center has seen their case mix index increase by almost 22%, but Fowler doesn’t view that as the most significant contribution of ChartWise:CDI. “Where we’ve seen the greatest impact as a result of the ChartWise software has been the substantial reduction in manual labor associated with documentation which has enabled us to start reviewing all patients and payers rather than just DRG payers,” she explained. “We’ve been able to re-direct those manual data entry and tracking hours and increase the amount of time the clinical documentation specialist has to spend reviewing the clinical details of the chart as well as the amount of face to face time educating physicians to ensure they understand and buy into our documentation process.”
“The management and staff at Colquitt Regional Medical Center made it clear from the start that what they were looking for in a new CDI program was efficiency,” said Mary Cooper, Vice President of ChartWise. “They needed the functionality provided by ChartWise:CDI to have quicker turnaround on their queries and to reduce the time they spend on data entry, on reviewing records and on compiling reports. Carla recognized what was possible with our application, and we’re pleased that their results have confirmed their decision. Colquitt’s high level of professionalism has made them an absolute pleasure to work with and an ideal fit for the ChartWise:CDI solution.”
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